How Does Confucianism Influence Health Behaviors, Health Outcomes and Medical Decisions? A Scoping Review

The aim of this study is to analyze the influence of Confucianism on health behaviors, health outcomes and medical decisions. The research was conducted using the following databases: PubMed, Scopus, CINHAL, PsycINFO and Web of Science, without restrictions of language and year of publication. The search process identified 833 publications matching the search criteria, and after the review process, 40 articles were included. Family is a central aspect of Confucianism, and it seems to affect participation in medical decisions, taking care of relatives, ethical dilemmas and mental health problems. Although most Confucianist influence seems to be positive, some ways of thinking could increase suffering, burnout and a delay in healthcare seeking. Understanding these values could help health professionals to deal with the growing contingent of patients with different cultures and religious beliefs.


Introduction
Interest in the study of religion/spirituality (R/S) and health has increased in the last decades (Lucchetti et al., 2016) generally supporting a positive association between R/S and health outcomes (Akerman et al., 2020). Some of the explanations for these findings are related to the beliefs of religious traditions which tend to avoid harmful behaviors and promote social connection and attendance to certain rituals that have beneficial effects on physical and mental health (Chen & Vanderweele, 2018). However, the training offered in universities and centers is scarce, reducing the ability of the main channel for decisions related to health, as well as the source of economic resources to face the health care of any of its members (Cao et al., 2011).
The societies that follow Confucianism function through defined hierarchies where different roles are established with their respective obligations and duties, which must be fulfilled to achieve personal harmony, while rejecting the pursuit of personal happiness originated by desires and impulses. This leads to the idea that mental health problems could be the result of lack of self-discipline and weakness of character (Huang & Charter, 1996).
Several studies have investigated the differences of beliefs of Confucianism in relation to other Western traditions. As an example, women have a pivotal role as primary caregivers for children with Down Syndrome, being responsible for maintaining the balance of the whole family in this situation (Choi & Van Riper, 2017). In relation to adherence to treatment, Chinese individuals have different postures as compared to Western individuals, accepting health recommendations unquestioningly and waiting for the health professional to finish the explanation without interrupting . Beliefs also have an important influence on ethical and critical situations, such as the rejection of the concept of "brain death", since Confucianist individuals do not understand the dichotomy of soul and body and, the moment the body granted by the parents, is eliminated, they and their ancestors are desecrated (Yang & Miller, 2015).
Since the Eastern societies and migration are increasing, addressing and understanding these cultural differences are important to health managers and healthcare professionals. Nevertheless, there has been little evidence compiling articles on the relationship between Confucianism and health behaviors and medical decisions and, to our knowledge, no scoping review. Our aim is, therefore, to assess through a scoping review the influence of Confucianism on the provision of health services, health behaviors and medical decisions.

Methods
A scoping review was carried out following the framework set out by Arksey and O'Malley (2005) and expanded upon by Daudt et al., (2013). Five stages were followed: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing and reporting the results. Then, a critical review to summarize the ideas and information was done. Authors have assessed carefully and clearly each reference and have took into consideration both the strengths and weaknesses of the articles under review.

Search Methods and Strategy
This scoping review has been registered on PROSPERO under ID CRD42021248022 and has followed the PRISMA guidelines. The search was conducted independently by two researchers between January and March 2021 in five electronic databases (PubMed, Scopus, CINHAL, PsycINFO and Web of Science). The following search 1 3 strategy was used: (confucianism OR confucian) AND (health OR "health promotion" OR lifestyles OR "healthy lifestyle" OR "health behaviors").
The search strategy was elaborated following the PICOTS structure as visualized in Table 1.

Inclusion and Exclusion Criteria
To be included, articles should be literature reviews or original articles using the following designs: cross-sectional, case-control, longitudinal cohort, descriptive, ecological or intervention studies and natural experiments.
There were no restrictions on language and year of publication. Exclusion criteria were published materials such as conference abstracts, case reports, editorials, letters to the editor and book chapters. Articles that related Confucianism with non-health outcomes (e.g., economics, politics) were also excluded, or those where the relationship between Confucianism and health was not the central focus of the results (e.g., theoretical essays or reflections).

Selection of Studies and Analysis
The first phase of the review was carried out by two researchers who independently assessed the titles and abstracts of all references. Duplicate articles were removed manually. A third researcher was in charge of reviewing the articles with discrepancies and including it or not. Included articles were then moved to the next phase.
In a second phase, data extraction and data verification were carried out by two researchers independently who assessed the full-text articles. The authors classified and then ranked the studies as being (i) poor, (ii) good or (iii) very good based on their strengths and errors detected mainly in the methodology, presentation of their results and discussion. All studies were classified as good or very good and all authors had to agree. The eligible articles are then included in Table 3, which

Results
The search process identified 833 publications matching the search criteria (Fig. 1). After removing duplicates, 685 articles remained, of which another 573 articles were excluded after screening the titles and abstracts. A total of 112 articles underwent full-text analysis. After reading the full text of the articles, the final sample included 40 studies: 13 using qualitative design, 13 quantitative studies, 9 narrative reviews, 4 essays and 1 systematic review.

Characteristics of the Included Studies
Forty articles addressing the influence of Confucianism on the provision of health care, health behaviors and medical decisions were included in this review. More than half of the references were published before 2017. Studies carried out in Eastern countries predominate (n = 32; 80%) and seven articles included immigrant population living in Western countries. The quantitative studies were predominantly crosssectional, and there was only one clinical trial. All qualitative methodology articles used interviews for data collection. Most participants included in the studies were females and the age of the participants ranged between 15 and 92 years. Four studies included only samples of women, and in eleven publications, their representation ranged between 50 and 80%. Familism, filial piety, harmony and benevolence were the main Confucian values included in the studies as shown in Table 2.

Confucian Values, Virtues and Beliefs Related to Health
Among all Confucian values, virtues and beliefs, those that place the highest value on the family stand out (Fig. 2). Familism is a Confucian value that puts family at the center of importance, and identifies that the human being is not self-sufficient for leading a good life independently from others (Chen & Fan, 2010). This implies respect to family relationships, mainly toward parents, perceived as filial piety or family reverence (Tai & Tsai, 2003), which is articulated as a starting point for the practice of benevolence (Zhang, 2010).
In this context, society is also understood as a family, which makes health behaviors linked to socially desirable values, in order to maintain dignity, social harmony and obedience (Garrison et al., 2018;Small & Blanc, 2021).s

Family as Focus of Medical Decision-Making
In Confucianism, medical decisions are highly influenced by its values such as familism, filial piety and harmony. In clinical practice, the family plays a pivotal role in health care decisions, in a way that the family informed consent is more important than the personal informed consent (Cong, 2004). The participation of the entire family ensures good relationship and avoids unnecessary suffering to the patient, using the justification that the patients could be deprived of information or the truth about their health status (Chen & Fan, 2010). However, this does not always imply excluding the individual from decision-making, but rather inviting physicians, patients and their family members, so that relevant persons must be involved and their diverse views respected and reflected before a harmonious agreement be made (Chen & Fan, 2010).
Another important value is the filial piety when parents become senile. In this situation, the oldest son is the responsible of taking care of them, including for making decisions (Tai & Tsai, 2003). This way of acting of the children is expected by their parents and in some circumstances avoid the search for healthcare, as shown in Journal of Religion and Health (2022) (2019) Medical decision-making is a responsibility assumed by the children, as a symbol of gratitude and respect toward their senile parents in compliance with filial piety. Older parents also feel the duty to take their children into account when making decisions Lee et al., (2016); Tai & Tsai, (2003) Familism implies sacrifice and not causing problems or embarrassment to the family. Therefore, when the patient suffers from stigmatizing health problems, reporting information to the patient individually protects the family from shame and discrimination by others in the community. Patients feel that they must manage these health problems without family members or healthcare professionals Chen et al., (2007) Hsiao et al., (2006) ;Park, (2012); Ran et al., (2021) 1 3 Journal of Religion and Health (2022) 61:2679-2725 Importance of facing chaos to achieve social harmony and promote community solidarity. Social solidarity acts as protective psychological factors Small & Blanc, (2021) a study among women with urinary incontinence (Kang & Crogan, 2008). In short, patients themselves consider that the head of the family should know the patient's medical diagnosis, including cancer, and make the decision to initiate treatments (Raposo, 2019), which also includes the "Do not Resuscitate" orders (Lee et al., 2016). Nevertheless, at the same time that children fulfill their obligations, parents must also develop personal morality as a mean to make family proud. Hence, they avoid discussing issues such as death and involve third parties in decision-making at the end of life, since individual acts could be interpreted as a less willingness to sacrifice (Lee et al., 2016). On the other hand, shame or guilt can also lead to solitary decision-making and refusal of healthcare professionals seeking care. In China, the stigma and social discrimination associated with HIV disrupts the traditional Confucian practice based on the beneficence of disclosing diagnostic information to family members. In these cases, the information to the patient is consistent with Confucianism, as patients prefer to address the disease themselves to protect their family from embarrassment by other members of the community (Chen et al., 2007).
Finally, there is also an important challenge to the Confucian medical decisionmaking model. The influence of Western vision on health laws would leave out of place the authority that families have in making decisions about hospitalization and treatment of family members (Fan & Wang, 2015).

Provision of Health Care and Health Behaviors
The family as the primary social unit and sacrifice is the basis of family care and functioning and, for this reason, the other family members should assume all the functions that the sick person cannot perform. This results in sacrificing employment and leisure time to have available time to take care of the relative. Confucian society accepts that care for older persons and dependents is carried out within the family, or when this is not possible, by the community or neighbors (Fan, 2006), while institutionalization is not considered an honor or the best option. Due to social changes and westernization of health, options for family-government collaboration  (Cao et al., 2011;Lo and Rusell, 2007;Zhang, 2010).
According to Confucianism, acting as family caregivers is part of a "Heaven's plan" (Yiu et al., 2021), and this type of care focuses on moral values such as embody benevolence, righteousness or justice, and propriety or courtesy (Holroyd, 2001(Holroyd, , 2003. The Confucian principles of mutual and reciprocal obligations are cyclic and works as follows: parents provide for their children's care and education while children practice filial piety, the responsibility to respect and care for their parents (Laidlaw et al., 2010;Park, 2012). They tend to give more importance to comply with this Confucian values than to achieve positive health results and for this reason, sacrifice of its own health in detriment of the other in need may be acceptable.
However, this review finds ambivalence between benevolence and filial piety. On the one hand, patients are pleased that their families expresses concern and love through caring. On the other hand, they stimulate self-care in an attempt to avoid being a burden to their family. In addition, self-care is practiced under the belief that positive moods can improve bodily health, hence the individual coping with suffering and pain as occurs in patients with cancer (Chen et al., 2008). Therefore, different strategies have been used to improve mental status, such as feeding livestock and poultry, planting vegetables and flowers, watching television, and attending recreational activities (Tao et al., 2014).
As part of caring, it is also important to mention that the adherence to Confucian norms are directly related to the use of traditional medicine, and healthy patterns of physical activity and eating (Lai & Surood, 2009;Rochelle & Yim, 2014). However, in Pang et al. (2015), parents conceptualized sport as valuable only if it contributed to substantial symbolic capital. Given that the fulfillment of filial piety implies respecting the health knowledge and preferences of the older persons of the family (for example, about TCM), this can sometimes be incorrect (Chang & Basnyat, 2017) or be a risk of acquisition unhealthy habits.
Traditional Confucian values also modulate sexual behaviors. Confucian women were less likely to choose an induced abortion (Chung, 2007), and young people had less premarital sex. In short, the Confucian tradition places greater emphasis on the spiritual pursuit of morality in young men, rather than affirming masculinity by overt sexual activity . Connecting with this, Confucianism emphasizes that people should procreate to carry on their family bloodline, so those with more traditional Confucian values have a worse perception of homosexuality (Feng et al., 2012).
Finally, the management of the COVID-19 pandemic situation is also related to positive health outcomes in these Confucian societies. Confucian values, including Tam Giao, tend to create a community spirit that influences high obedience rates, greater attention to cleanliness, and the promotion of collective solidarity (Mayer et al., 2020;Small & Blanc, 2021).

Dignity, Death, and Body Donation
Confucian principles of morality and dignity encourage individuals to continue living, to fulfill their responsibilities in the family and in society. In this context, deciding individually to end life has a negative impact on family reputation and is therefore considered totally inappropriate. However, preserving the quality of lifeequivalent to moral quality or dignity, which is essential to live in a Confucian society, allows individuals to decide not to deliberately extend life using technological advances (i.e., dysthanasia) (Li & Li, 2017).
Regarding studies focusing on organ donation after death, these reflect the influence of filial piety and benevolence (Cai, 2019;Zhang et al., 2020). Filial piety could get in the way of organ donation, since although it entails an act of compassion and righteousness toward others, based on this Confucian value, the basic duty of the children is keeping the body in the condition in which it was given to him/her by his/her parents. Therefore, Confucianism does not advocate body donation, justifying this posture as maintaining the love and respect for the family and the dying person (Cai, 2019;Nie and Gareth Jones, 2019).
However, values such as humaneness or benevolence comprise the body donation as virtuous acts to promote virtue cultivation and honor the relatives (Jones & Nie, 2018). In cases such as the donation of organs from prisoners or people who have committed dishonorable acts for the family, the donation could be approved by the family (Cai, 2019;Jones & Nie, 2018).

Mental Health
Some Confucian values and principles are considered protective elements of mental health. For instance, the Zhongyong ("Doctrine of the Mean"-one of four Confucian texts) is suggested to maintain harmony of mind and alleviate depressive symptoms (Yang et al., 2016). Likewise, a previous study found that those with higher levels of Confucian work values were able to respond better to stressful situations at work (Siu, 2003). This was also observed in the COVID-19 pandemic where Confucian values were considered important markers to the development of resilience. As Small and Blanc (2021) point out, Tam Giao (which includes Buddhism, Confucianism and Taoism) may have tools to provide protective psychological factors that are derived from social solidarity, and a positive view of government actions to prevent the spread of the COVID-19 pandemic.
Despite the aforementioned positive effects, it is important to highlight that fate thinking (the core of Confucian thoughts) was also associated with higher depressive and anxiety symptoms (Lihua et al., 2017). A previous work has found that obeying to the filial piety and the harmony of Confucian doctrine increased suicide cases in women with depression (Jia & Zhang, 2017). This could be explained because Confucian interpersonal peace can be affected if culturally accepted expectations and behaviors are not met, with feelings of shame and guilt appearing, which can lead to depressive problems (Garrison et al., 2018;Hsiao et al., 2006). (2022) 61:  Finally, in Confucianism, mental health problems are often associated with bad life habits, generating guilt and social stigma for both individuals and their families. To avoid recognizing these problems, the search for treatment is delayed and patients are isolated and admitted to health centers. This makes the family feel dishonored and guilty, and the individuals for their part, feel the failure of having raised children who do not honor filial piety (Park, 2012;Ran et al., 2021).

Journal of Religion and Health
The summary of all studies included in this review is shown as "Appendix 1".

Discussion
As shown in our review, Confucianism is still very common in the Eastern traditions and influences many aspects of life in countries such as China, Japan and Korea with regard to mental and physical health, quality of life and ethical situations (Abdullah & Brown, 2011;Chiu, 2001;Li & Hou, 2012). As previously shown, family is the most important aspect of Confucian values and all decisions are based on the good of the whole family, in other words, "there is no self in Confucian teachings" (Tung, 2010). In this context, the family tends to prevent the isolation and the detrimental psychological effects of cultural alienation (Lee, 2015). This is supported by the fact that this relationship is maintained even after migration to Western countries, as seen in Chinese immigrants in the USA and Canada (Tung, 2010). Family is so important to this system of beliefs that parents take care of their children under an authoritarian parenting style, to comply with obedience to the older persons (Hu et al., 2014). Likewise, it is the responsibility of youngers to take care of the older adults. Caregivers experience pressure from the local community to keep the family together. Raising a kin's child is not only a family matter; rather' it indicates social merit and involves the risk of being judged by others (Hu et al., 2014).
Although family can be a source of union and promotion of health, the pressure of community and the detriment of own health to the health of family members could be deleterious as well. For instance, familial obligations may become first than health care and family opinions have a stronger influence over health professionals, in a way that treatments tend to start using medications provided by family members (Tung, 2010).
Ethical issues, medical decisions and end-of-life care are other important areas influenced by Confucianism. As Confucius stated, "The body and hair and skin are received from the parents, and may not be injured" (Lin, 2009: 186). This statement shows the importance of filial piety and results in several consequences for organ donation and ethical dilemmas (Cai, 2019;Zhang et al., 2020). Health professionals should be aware of this characteristic of Asian patients in order to provide an appropriate assistance.
In relation to public health implications, it seems that there is an apparent divergence between modern healthcare systems and Confucian values. Western traditions tend to be very distinct from Eastern traditions and treating Confucian immigrants is no easy task, since most of the Western systems are not prepared to address these patients, resulting in worse outcomes such as poor healthcare and conflicts (Tung, 2010). However, this divergence is now appearing even in the Asian countries such as China. The healthcare reform in China has increase the technology and costs of healthcare, moving it away from the Confucian values of benevolence, humanity and justice (Cao et al., 2008;Du, 2008). According to Cao et al. (Cao et al., 2008), it is now essential that the new Chinese healthcare system is attached to traditional Confucian cultural concepts such as "people as the foremost", "the benevolent man loving others", "medical treatment as the principle and humanity as the method", and "valuing justice above material gains". This will make this system more holistic and inclusive.
From a Western perspective, in countries with consolidated and modern healthcare systems and high number of Asian immigrants, it is essential to understand Confucian values, incorporate them as cultural competencies and train health providers to deal with their positive and negative aspects, fully integrating these immigrants.
All this aspects could be affected during the currently COVID-19 pandemic, and this pandemic shape the future of religious ethics in general and in Confucianism in particular, due to the religious, cultural, ethical, and political implications. For adherents of Confucianism only through caring for others can they possibly care for themselves, so, the life and salvation do not an individual matter but a familiar and community aspect, and this is in contrast to a general vision of society that insists on a foundational individualism or ethnocentrism in ethics and politics (Alimi et al., 2020).

Study Limitations
The present review has some limitations that should be highlighted. Some keywords related to Confucianism such as "benevolence", "family", and "justice" were not used. A more broad approach could have contaminated our findings, resulting in a huge number of unrelated articles. Therefore, our approach was to include the specific term "Confucianism" and "Confucian". Likewise, although several databases were searched, no Chinese databases were used, and it is possible that some studies have not been included. In addition, the lack of clinical trials within the articles included in our scoping review could be considered a limitation. Finally, although the authors shared strengths and errors of the articles and agreed to classify them as good or very good, no methodological quality control tool (i.e., STROBE, SRQR, and CONSORT) was used.

Conclusions
Our review has provided further evidence regarding the influence of Confucianism on health behaviors, health outcomes and medical decisions. Based on our findings, family is the central aspect of Confucianism and it seems to affect many dimensions of life, including the participation in medical decisions, taking care of relatives, ethical dilemmas (e.g., organ donation and end-of-life issues) and mental health problems. Although most of the influence seems to be positive and lead to better outcomes, some ways of thinking could be deleterious as well, increasing suffering, burnout, and a delay in healthcare seeking. Understanding these values could help health managers and health professionals to deal with the growing contingent of patients with different views and cultures.
With regard to future implications for clinical practice, given that international migration is increasing and it will cause changes in the sociocultural demographics of many countries, it would be convenient to replicate this type of research with other religious affiliations, aiming to adapt clinical care.

Appendix 1
See Table 3   and their wishes are being considered, the medical decisions are made by the whole family as codecision-makers, with a representative family member acting as a link between the patient and the doctor The involvement of a family member is a protection for the patient, but he / she is not fully informed of the illness because of the physicianregarding limitations of disclosure. However, neither the patient nor the family member expressed dissatisfaction with the current DFPR model 1-16 years Elderly dependent: 65-91 years Based on the Confucian sense of order, families must regulate bodily illness (symbolic of disorder) beyond the filial piety understandings, to cover bodily needs (i.e., ingestion of food and medicine, excretions, washing, assisting with toileting, dressing), and to affirm their own social identity through social relationships with their dependents. This generates high levels of fatigue in caregivers from the incessant demands of meeting family duties and concern about death at home with their children, as the family is as a decision-making system where the filial behavior of children seek the best for their parents; 2) due to familism, they were concerned for causing problems and not showing sacrifice; 3) they considered death to be something natural and they did not want to go against nature Forty-one studies in Pacific Rim region Many Asians perceive persons with mental illness as representing the family's mental illness and their bad past, and also mental illness is considered a strain on collective systems within Asia, including families or social groups. Therefore, this people might suffer stigmatizing and more physical threat. Avoiding disclosure of mental illness in order to save face in Confucian societies might lead to delayed treatment seeking and sense of cultural superiority) was predictive of TCM utilization and of the belief in the effectiveness and superiority of TCM over WM. However, tolerance and harmony was not predictive of using TCM, and these participants took a more neutral point of view when comparing both models of medicine  Age: 20-55 years More so two-thirds of the participants said it should be revealed diagnosis of cancer to the head of the family. Concerning the course of the treatment, 57.1% indicated that the decision should be made either by the father or the husband of the patient (fulfilling their role and position in the family), and 7.4% stated that decision on a major operation should be made by the patient Filial piety implies respect and gratitude toward parents, so when parents become senile, usually the oldest son, assume the duty to take care of them, including making decisions On the one hand, the participants showed independence using stoma appliances and handling peristomal skin problem so that they do not feel themselves not being a burden to family, and to regain the power to repay their families. On the other hand, they were pleased that their families occasionally changed their stoma appliances expressing concern and love Yang There is a correlation between Confucianism funeral belief (when a person dies, the body must be returned in the original form) and the willingness to donate one's body (p < 0.001). Participants with no Confucianism funeral belief were 9.8 times more willing to donate their bodies